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Teachers’ Recognition and Referral of Anxiety Disorders in Primary School Children

Headley, C. J.

Campbell, M. A.

Queensland University of Technology

Clea Headley BPsycSc (Hons)

School of Psychology & Counselling, Faculty of Health

Level 5, O Block, B Wing, Queensland University of Technology

Victoria Park Road, Kelvin Grove, Queensland, 4059

E: clea.headley@connect.qut.edu.au M: 0421 234 083

Clea Headley is a provisional psychologist currently studying a Master of Clinical

Psychology at the Queensland University of Technology. Her main research and clinical

interests include working with children and adolescents who experience mental health

problems, particularly anxiety disorders.

Corresponding author

Associate Professor Marilyn Campbell

School of Leaning and Professional Studies, Faculty of Education

A Block, Queensland University of Technology,

Victoria Park Road, Kelvin Grove, Queensland, 4059

E: ma.campbell@connect.qut.edu.au T: (07) 3138 3806 F: (07) 3138 8265

Dr Marilyn Campbell is an associate professor at the Queensland University of Technology,

coordinating the Masters of Education program. Her main interests include the prevention

and intervention of anxiety disorders in young people and the effects of cyberbullying in

schools. She is the author of the Worrybusters series of books for anxious children.

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Abstract

This study investigated the ability of primary school teachers to recognise and refer children

with anxiety symptoms. Two hundred and ninety-nine primary school teachers completed a

questionnaire exploring their recognition and referral responses to five hypothetical vignettes

that described boys and girls with varying severity of anxiety symptoms. Results revealed

that teachers were generally able to recognise and make the decision to refer children with

severe levels of anxiety. However, they had difficulty distinguishing between children with

moderate anxiety symptoms and a severe anxiety disorder. Female teachers were more likely

to refer children than were male teachers. The implications and future research are discussed.

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Teachers’ Recognition and Referral of Anxiety Disorders in Primary School Children

The experience of anxiety is considered a natural part of children’s development.

However, while most children learn to manage their anxiety, approximately 3 – 24% of

children below the age of 12 develop significant anxiety problems that interfere with daily

functioning (Cartwright-Hatton, McNicol, & Doubleday, 2006). Of these, approximately 2.5

– 5% of children meet criteria for an anxiety disorder; that is, when children exhibit a fear

response in the absence of a real danger (Costello, Mustillo, Erkanli, Keeler, & Angold,

2003; Ford, Goodman, & Meltzer, 2003; Ollendick, King & Yule, 1994).

Research has indicated that anxiety disorders can have detrimental consequences on

children, both in the short term and long term. Excessive anxiety can lead to significant

disability, equally problematic to that of depression (Ezpeleta, Keeler, Erkanli, Costello, &

Angold, 2001). Studies have indicated that children who experience anxiety disorders have

lower academic achievement (Ialongo, Edlesohn, Werthamer-Larsson, Crockett, & Kellam,

1995), problems with peer and parental relationships (Ezpeleta et al., 2001; Strauss, Frame &

Forehand, 1987), and general impairments in social and psychological functioning (Messer &

Beidel, 1994). The difficulties associated with anxiety disorders, such as excessive school

absenteeism (Last & Strauss, 1990) and impairments in peer relationships, can lead to long-

term poor vocational adjustment (Hibbert, Fogelman, & Manor, 1990), negative self-

perception (Rubin, 1985), poor self-esteem (Strauss et al., 1987) and an increased likelihood

of psychological disorders later in life (Bittner, Egger, Erkanli, Costello, Foley, & Angold,

2007; Copeland, Shanahan, Costello, & Angold, 2009; Kovacs & Devlin, 1998).

Without treatment, anxiety disorders are relatively persistent, indicating that they are

not an experience children outgrow naturally. Young people who have an anxiety disorder

are at a significantly higher risk to continue to have an anxiety disorder as they transition

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from childhood to adolescence (Bittner et al., 2007) and from adolescence to early adulthood

(Pine, Cohen, Gurley, Brook, & Ma, 1998). This study will refer to anxiety disorders as an

overall classification given the high co-morbidity between them and the similar outcomes to

treatment approaches for specific anxiety disorders (Costello, Egger, & Angold, 2005;

Saavedra, Silverman, Morgan-Lopez, & Kurtines, 2010).

Girls are almost twice as likely to experience an anxiety disorder compared to boys

(Costello et al., 2003; Lewinsohn, Gotlib, Lewinsohn, Seeley, & Allen, 1998). However, it is

unclear exactly why this is the case. It might be that the experience of anxiety in children is

different between genders due to the result of socio-cultural factors. Specifically, the

expression of anxiety and fear is considered less acceptable for boys, hence less tolerated in

boys than in girls (Stevenson-Hinde & Shouldice, 1993). This might lead to boys under-

reporting anxiety levels to avoid appearing weak and vulnerable, which would be inconsistent

with their typical masculine gender role (Barlow, 1988). It is likely that parents and other

socialisation agents (e.g. teachers, peers) may encourage children to conform to gender

stereotyped behaviour by accepting and reinforcing anxious behaviours in girls, and activity

and assertiveness among boys (McLean & Hope, 2010).

Considering the debilitating and lasting impacts of anxiety disorders for children, and

that they rarely remit without treatment (Flament et al., 1990; Kovacs & Devlin, 1998), it is

important to ensure that preventative measures are taken and early intervention is provided.

However, given the prevalence of anxiety disorders in children, very few children are

identified and referred for treatment (Costello & Janiszewski, 1990; Zahner & Daskalakis,

1997). This may be because children rarely seek help for mental health concerns on their own

initiative (Ford, Sayal, Meltzer, & Goodman, 2005) as they rely on adults to recognise the

problem and take appropriate action to seek assistance.

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Parents are the adults most likely to initiate the help-seeking process for their children

when they recognise that there is a problem (Lyneham & Rapee, 2007; Sayal, 2006). Parents,

however, often lack the skills to identify mental health problems in their children. This is

especially true about anxiety problems, with 61% of parents of children with an anxiety

disorder not recognising there was a problem, and 67% not acknowledging that their child’s

diagnosed anxiety disorder had any impact on their family (Teagle, 2002). Parents may not

identify anxiety problems in children because they may experience anxiety themselves, hence

view it as normal behaviour. This is because research has established that anxiety is a highly

familial disorder, with children with anxiety disorders being considerably more likely to have

a parent with an anxiety disorder when compared to other children (Klein, 2009; Last,

Hersen, Kazdin, Francis, & Grubb, 1987; Last, Hersen, Kazdin, Orvaschel, & Perrin, 1991;

Lieb, Wittchen, Hofler, Fuetsch, Stein, & Merikangas, 2000). Parents also do not have the

opportunity to compare their child’s behaviour with that of other children and this may make

it difficult for them to have an understanding of non-normative behaviour.

A parent’s ability to recognise problems also predicts their choice to refer their child

to mental health services. Specifically, if parents do not perceive a problem (which is the case

for the majority), they do not access services on behalf of their child (Teagle, 2002). Other

barriers to parents referring their children for mental health treatment includes the stigma

surrounding mental health services, the costs of treatment, the desire to handle the problems

within the family unit, and a fear of not having control over the treatment process (McKay,

Stoewe, McCadam, & Gonzales, 1998; Thurston & Phares, 2008).

Given this finding, it is important to ensure that access to mental health services is not

dependent solely on parents’ perceptions of excessive anxiety in their children. Schools are

an ideal setting in which to identify and respond to mental health concerns in children

(Rickwood, 2005). Teachers are in a key position to identify mental health problems, such as

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excessive anxiety, in their students and have the ability to refer to mental health services both

within the school as provided by the guidance counsellors and outside the school with

community-based organisations (Rickwood, Deane, Wilson, & Ciarrochi, 2005). Their

understanding of typical behaviour for a particular student and their experience of a wide

range of children’s behaviour allows them to identify non-normative behaviour. Teachers

therefore have an important role in the identification of anxiety disorders in children and can

use their expertise to appropriately refer to mental health services (Loades &

Mastroyannopoulou, 2010; McGorry, Purcell, Hickie, & Jorm, 2007).

While it is clear that many parents have difficulty identifying mental health problems

in their children (Ford et al., 2005; Sanders et al., 1999; Zubrick, et al., 1995), very little

research has examined whether teachers have the ability to identify anxiety disorders in

children. A second question is whether, once identified, teachers refer these children to

mental health professionals. Examination of the current coursework for education degrees

reveals that teachers have little to no education or training in children’s mental health as part

of their teaching qualifications (Gowers, Thomas, & Deeley, 2004). This is congruent with

reports from teachers who often feel inadequately prepared to recognise and manage students

with mental health concerns because they have not received this training (Green, Clopton, &

Pope, 1996; Rothi, Leavey, & Best, 2008; Rothi, Leavey, Chamba, & Best, 2005). If teachers

are not receiving training, it is doubtful that they have the knowledge of the signs and

symptoms of excessive anxiety in children. As most referrals for children with mental health

concerns are made when children are in primary school (Harris, Gray, Rees-McGee, Carroll,

& Zaremba, 1987), this study will focus on research with primary-aged children.

The research available in this area has focused broadly on comparing teacher’s

identification and referral of children with internalising and externalising disorders. It has

been found that teachers frequently overlook children with internalising problems as these

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children are often well behaved (Molins & Clopton, 2002) or teachers believe these problems

will improve as the child matures (Green et al., 1996). Pearcy, Clopton & Pope (1993) found

that teachers were less able to identify internalising problems in the classroom setting,

especially when the child’s symptoms were severe. Furthermore, when teachers did refer,

they were more likely to refer children with externalising disorders compared to internalising

disorders. It was suggested that this could be due to the difficulty of managing children with

externalising problems in the classroom (Green et al., 1996; Pearcy et al., 1993). There were

no differences in recognition or referral of boys or girls with problems.

Loades and Mastroyannopoulou’s (2010) recent study has confirmed Pearcy and

colleagues (1993) earlier research finding that although teachers are able to recognise the

existence of psychological disorders, they were far more concerned about children with

externalising disorders than internalising disorders. The gender of the child influenced the

recognition of the problem with teachers more accurately recognising a problem when a boy

had an externalising disorder compared to a girl with an internalising disorder. Similarly,

Molins and Clopton (2002) found that teachers were more concerned and more likely to refer

boys and externalising behaviour problems compared to girls and internalising behaviour

problems. However, proportionately, there were similar percentages of children referred from

each problem type and gender, indicating that the greater frequency of referrals for boys and

externalising problems was due to the greater number of children originally identified as

having concerning behaviour. Given the high prevalence of internalising disorders, these

findings would indicate that teachers might have difficulty initially recognising symptoms of

internalising disorders.

Based on the limited research of teacher’s identification and referral of children with

excessive anxiety, this study investigated the ability of teachers to identify anxiety problems

of differing severity in children and their subsequent decisions whether or not to refer to

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mental health services. The influence of both the child’s and teachers’ gender on

identification and referral of anxiety was also examined. That is, whether boys with anxiety

were recognised and referred as much as girls, and whether male and female teachers

responded similarly in their recognition and referral of children with anxiety.

Method

Participants

Three hundred and fifty-eight teachers were recruited from 27 primary schools in a

large Australian city. Fifty-nine participants were excluded from the sample either because

they were not classroom teachers or there was missing data, leaving a total of 299

participants. Sixty-four participants were male (22%) and 234 were female (78%) (1

participant did not reveal gender). The mean age was 40 years (SD = 11.29) with a range 21

to 71 years. The mean number of years of teaching was 16 (SD = 11.19).

Measures

Teachers’ Anxiety Identification and Referral Questionnaire (TAIRQ). The

TAIRQ is a four part self-report questionnaire developed by the researchers for use in this

study. The results of two sections of the TAIRQ will be reported in this study and the

subsequent sections will be reported in a subsequent paper. The sections to be later examined

explored qualitative responses to the definition of anxiety and teachers’ identification of signs

and symptoms of excessive anxiety.

The first section of the TAIRQ comprised socio-demographic information on age,

gender, teaching experience (years and grade-level), status of teaching career, and previous

referring history. The second part of the questionnaire was based on five vignettes, four of

which showed internalising disorders used in previous research (Green et al., 1996; Pearcy et

al., 1993). These four vignettes were changed to reflect children with specific anxiety

problems, and increased in severity for each vignette. Symptoms of anxiety, selected from the

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DSM-IV-TR and Spence Children’s Anxiety Scale were either added or excluded to

represent varying degrees of severity of anxiety (American Psychiatric Association, 2000;

Spence, 1998). A fifth vignette was added to represent a child with minimal symptoms of

anxiety and extroverted tendencies to clearly distinguish it from the other vignettes (see

appendix for the vignettes).

Once finalised, these five vignettes were sent to nine experts in childhood

psychological problems who ranked them according to severity of presenting anxiety. The

vignettes were amended according to feedback. Following each vignette, a set of questions

was posed. The questions that will be analysed in this study asked teachers, “If this child was

in your classroom, would you refer him/her to the guidance counsellor?” (5 – definitely

would to 1 – definitely would not) and invited teachers to rank order the five children from

the vignettes in order of need of referral. The other questions explored qualitative response to

teachers’ responses on need of referral, and the rates of encountering and previous referral of

children similar to the description. The questionnaire was produced in four versions to

randomise gender (i.e. half of the questionnaires included boys names and half girls names)

and to randomise and counterbalance the order of the vignettes in the questionnaire to

manage order effects. In the final sample, 51% of the questionnaires described boys and 49%

described girls.

Procedure

Teachers completed the questionnaire either in a staff meeting with a researcher

present or posted the questionnaire back to the researchers in a reply-paid envelope. The

questionnaire took approximately 10-15 minutes to complete.

Results

Data Screening

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The assumption of normality was assessed by inspecting the skewness and kurtosis of

each variable used in the analysis and the presence of outliers. Although initial screening

revealed that several variables had high levels of skewness and kurtosis, Cook’s distance was

not greater than 1 (max = 0.054) so all variables were retained. The assumption of

homogeneity of variance and variance-covariance was assessed using Levene’s test and

Box’s test. To account for violations of normality and homogeneity of variance and variance-

covariance, Pillai-Bartlett trace was used because it is a more robust statistic (Field, 2009).

Where Levene’s statistic was significant, a more conservative alpha level of .025 was used to

correct for this (Keppel & Wickens, 2004). Despite the violation of normality, there were

greater than 20 degrees of freedom for error for all analyses (df = 284) indicating that the

analyses were robust (Tabachnick & Fidell, 2007).

The assumption of sphericity was assessed using Mauchly’s test. This statistic was

significant for each analysis indicating a violation of sphericity. Therefore, degrees of

freedom were corrected using Greenhouse-Geisser estimates of sphericity.

Identifying Children in Need of Referral

The descriptive statistics for teachers’ ranking of the children in the vignettes

according to need of referral (N=246) can be seen in Table 1. Several teachers’ responses

were excluded because there was either missing data or an incorrect ranking procedure used.

Teachers correctly ranked the need for referral according to severity of anxiety in all but one

case. This was for the child with moderate anxiety symptoms who teachers reported in

greater need of referring than the child with a severe anxiety disorder.

A 2 x 2 x 5 mixed model multivariate analysis of variance (MANOVA) was

performed to investigate the effects of severity of anxiety, child’s gender and teacher’s

gender on teachers’ rankings of need of referral. Results revealed a significant multivariate

main effect of severity of anxiety on the ranked need of referral of each child in the vignettes

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V = 0.84, F (4, 237) = 301.96, p <.001, partial 2 = 0.84. There were no significant two-way

or three-way interactions and no significant main effect for child or teacher gender.

Table 1

Mean (Standard Deviation) for the Rank Given to Children According to Need of Referral

Severity of anxiety M (SD)

Very severe anxiety disorder 1.47 (.79)

Severe anxiety disorder 2.77 (1.01)

Moderate anxiety symptoms 2.52 (1.01)

Mild anxiety symptoms 3.46 (0.88)

Minimal anxiety symptoms 4.78 (0.77)

Influence of severity of child anxiety. Results revealed a significant main effect of

severity of anxiety on the need to refer children in the vignettes, F (3.53, 847.78) = 257.83, p

< .001, partial 2 = 0.52. There were no significant two-way or three-way interactions.

Polynomial contrasts were used to test the significance of a linear trend in teachers’ ranking

of children in need of referral according to the severity of anxiety. The contrast analysis

indicated a significant positive linear trend, F (1, 240) =885.69, p < .001, partial 2 = 0.79. In

addition to a significant linear trend, a curvilinear trend was also significant due to the rank

given to the vignette describing a child with moderate anxiety symptoms (see Figure 1).

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Figure 1. Teachers’ mean responses to ranking the children in need of referral for each level

of severity of anxiety described in the vignettes.

Using a Bonferroni adjustment to control for Type 1 error, post hoc pairwise

comparisons indicated that teachers’ rankings on the need to refer children in the vignettes

differed significantly across and between all of the severity levels of anxiety, p = .001. This

indicates that teachers were generally able to correctly identify which children were in most

need of referral based on their presenting anxiety symptoms. However, they did have

difficulty distinguishing between a child with moderate anxiety symptoms and a child with a

severe anxiety disorder.

Decisions to Refer Children with Anxiety

To determine whether teachers’ decisions to refer a child was influenced by the

severity of the child’s anxiety, the child’s gender or the teachers’ gender, a 2 x 2 x 5 mixed-

model MANOVA was performed. There was a significant multivariate main effect of

severity of anxiety on teachers’ decision to refer a child, V = 0.837, F (4, 281) = 360.49, p <

1

2

3

4

5

Verysevereanxietydisorder

Severeanxietydisorder

Moderateanxiety

symptoms

Mildanxietysymptoms

Minimalanxietysymptoms

Teachers'meanresponsestoneedof

referral

Severityofanxietydescribedinvignettes

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.001, partial 2 = 0.84. There were no significant two-way or three-way interactions.

However, there was a significant main effect for teacher gender but not for child gender.

Influence of severity of child anxiety. Results revealed a significant main effect of

severity of anxiety on the decision to refer a child, F (3.89, 1104.65) = 315.57, p < .001,

partial 2 = 0.53. There were no significant two-way or three-way interactions. Polynomial

contrasts indicated a significant negative linear trend in decision to refer according to the

severity of anxiety, F (1, 284) =1149.63, p < .001, partial 2 = 0.80. The polynomial tests of

curvilinear trends were also significant (see Figure 2). However, the examination of the graph

indicates that this is due to the unexpected scores for the child with moderate anxiety

symptoms.

Figure 2. Male and female teachers’ mean responses for their decision to refer for each level

of severity of anxiety described in the vignettes.

Using a Bonferroni adjustment to control for Type 1 error, post hoc pairwise

comparisons indicated that the teachers’ decision to refer each child in the vignette differed

4.17

2.91

3.45

2.45

1.39

4.44

3.39 3.54

2.76

1.5

1

2

3

4

5

Verysevereanxietydisorder

Severeanxietydisorder

Moderateanxiety

symptoms

Mildanxietysymptoms

Minimalanxietysymptoms

Teachers'meanresponsestoneedof

referral

Severityofanxietydescribedinvignettes

MaleFemale

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significantly across and between all severity levels of anxiety, p .001. This indicates that

teachers generally decided to refer children based on the severity of presenting anxiety

symptoms. However, teachers decided to refer moderate anxiety symptoms more than a

severe anxiety disorder.

Influence of teacher gender. For teachers’ referral of children in the vignette, the

Levene’s test was significant for two vignettes. Hence, Pillai’s trace and a more conservative

alpha were used for all analyses. Results revealed a significant main effect of teachers’

gender on decision to refer a child from the vignette, F (1, 284) = 10.31, p = .001, partial 2 =

0.04, indicating that female teachers (M = 3.12, SE = 0.04) decided to refer more than male

teachers (M = 2.87, SE = 0.07). There was a non-significant main effect of child’s gender, F

(1, 284) = 0.37, p = .54, partial 2 = 0.001, and a non-significant interaction, F (1, 284) =

0.70, p =.41, partial 2 = 0.002.

Discussion

The aim of this study was to investigate teachers’ recognition of children with

excessive anxiety and their decision to refer. This study was also interested in whether the

child’s gender or teacher’s gender influenced recognition and referral responses. The results

revealed that teachers could generally identify which children had the most severe levels of

anxiety and which children had the least severe levels of anxiety. However, teachers had

difficulty in distinguishing between a child with moderate anxiety symptoms and a child with

a severe anxiety disorder. Although there is no previous research specifically investigating

this area, these findings may provide a better insight into the results of Pearcy and colleagues

(1993). For children with a severe anxiety disorder (but not very severe), teachers may have

difficulty differentiating these children from those with subclinical moderate anxiety

symptoms. This is, in part, consistent with the finding that teachers are less able to identify

anxiety symptoms in children when they are severe (Pearcy et al., 1993). However, teachers

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were still able to recognise the extreme ends of the anxiety spectrum. Therefore, it may be

that teachers can recognise when anxiety levels are very severe, but they may have difficulty

distinguishing symptoms that border on the clinical and non-clinical range.

Teachers’ qualitative responses indicated that they placed great importance on peer

interaction and the development of social skills (Headley & Campbell, 2011). They viewed a

child’s moderate anxiety symptoms as problematic and potentially indicative of a bigger

issue. This may indicate that teachers have a preference for identifying signs of children’s

social well-being, which may come at the cost of identifying excessive anxiety problems.

This is consistent with the report that teachers have difficulty identifying symptoms of

internalising problems (Molins & Clopton, 2002), and that social difficulties may be more

easily identified.

A second finding of this study was that teachers’ decisions to refer a child with

anxiety were influenced by the severity of anxiety. Whilst teachers decided to refer the very

severe anxiety disorders, they were more likely to refer moderate anxiety symptoms over a

severe anxiety disorder. This is similar to their pattern of identifying anxiety. This may be

due to reasons previously discussed; specifically, that teachers viewed moderate anxiety

symptoms that reflected social difficulties as having greater need for referral compared to

symptoms consistent with a severe anxiety disorder. This is consistent with findings that

children with internalising problems may be overlooked in the classroom due to good

behaviour (Molins & Clopton, 2002) and teachers may be more likely to recognise children

in need of referral who have obvious social difficulties.

An interesting finding that contributes to our current understanding of teacher’s

referral patterns was that female teachers were more likely to refer children to the guidance

counsellor compared to male teachers. No previous research has examined the influence of

teacher’s gender on referral rates. However, it may be hypothesised that the culture

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surrounding mental health problems and gender may have influenced this result. Previous

research has indicated that it is more acceptable for females to display anxiety compared to

males, and that this may be due to males conforming to gender roles of being tough and

fearless (Barlow, 1988; McLean & Hope, 2010; Stevenson-Hinde & Shouldice, 1993). It may

be that these socialised gender role beliefs led to male teachers identifying less need for

referral as it is better to ignore this problem and hope it will go away because the stigma of

identification is greater than the cure. As this is nascent research, further research is needed to

determine if these findings are replicable. It is also important to consider the unequal gender

ratio of teachers in the current sample; however, it was representative of the unequal gender

ratio in the primary teacher population. Future studies should attempt to sample more equal

numbers of male and female teachers when investigating the effects of teacher gender.

Consistent with Pearcy and colleagues (1993), there were no child gender differences

in teachers’ recognition or referral of boys or girls. This is inconsistent with epidemiological

studies and research that has indicated that teachers are more likely to recognise (Loades &

Mastroyannopoulou, 2010) and refer (Molins & Clopton, 2002) boys compared to girls.

However, the type of problem experienced by the child (i.e. internalising or externalising)

may have influenced previous findings. The lack of gender difference found in the present

study may be because teachers have focused primarily on the content of the vignettes and

disregarded the gender of the child. Future research specifically investigating the influence of

a child’s gender on recognition and referral of anxiety disorders may benefit from employing

an alternative research design that focuses directly on differentiating children’s gender.

This study had a significant strength in the sample size obtained and the sampling

methodology employed. By attending each school’s staff meeting, the sample of teachers was

likely unbiased because most, if not all, teachers at the meeting completed the questionnaire.

Therefore, a more representative sample was obtained and not limited to those teachers with a

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specific interest in children’s mental health. The vignettes used in this study had been

previously validated and were adjusted by experts in the field to represent children with

differing levels of anxiety. This likely made the vignettes as realistic as possible whilst

maintaining consistency.

Whilst having a strong methodological base, the limitations of using vignettes have

been documented in previous research (Loades & Mastroyannopoulou, 2010). Specifically,

teachers may have responded to the vignettes with an idealistic response that may be different

from their usual identification and referral patterns within the classroom setting (Lucas,

Collins & Langdon, 2009; Norcini, 2004). It is worth noting that vignettes are limited in their

ecological validity and that teachers may not have responded to the vignettes in the same

manner that they would respond to a child with mental health problems within their

classroom.

Although based on previous research, the current vignettes have not been tested for

validity and reliability, which may limit the interpretation of the results. However, given the

little changes that were made to the previously validated vignettes, this likely did not have a

significant impact on the results. The generalisability of the findings may also be limited as

teachers were sampled from one major city in Australia. However, the geographical locations

of the schools were widely dispersed throughout that city and would represent a diverse

sample for this region. This study only identified teachers’ recognition of anxiety (as a

measure of teachers’ knowledge of anxiety) as a barrier to referring. Therefore, future

research could explore other barriers teachers face in preventing them from referring children

with mental health problems.

Based on the findings of the current study, it is clear that teachers can recognise and

would refer children with anxiety problems. However, it appears that they have difficulty

distinguishing anxiety when it is at a moderate to severe level. It is important for teachers to

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be able to make this distinction, as many children experiencing an anxiety disorder may not

be referred for treatment. Additionally, given the nature of anxiety disorders, they are likely

suffering silently within the classroom setting. Therefore, teachers may benefit from

receiving specialised training and ongoing professional development in children’s mental

health. Educational efforts should also focus on minimising the cultural biases about gender

and mental health problems, as this might have influenced male teachers’ lower referral

patterns. If we can equip teachers with the necessary skills to identify excessive anxiety in

children, then we can improve the educational, social, and psychological outcomes for all

children.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental

disorders: Text revision (4 ed.). Arlington, VA: American Psychiatric Association.

Barlow, D. H. (1988). Anxiety and its disorders: The nature and treatment of anxiety and

panic. New York: Guilford Press.

Bittner, A., Egger, H. L., Erkanli, A., Costello, E. J., Foley, D. L., & Angold, A. (2007).

What do childhood anxiety disorders predict? Journal of Child Psychology and

Psychiatry, 48, 1174-1183. doi:10.1111/j.1469-7610.2007.01812.x

Cartwright-Hatton, S., McNicol, K., & Doubleday, E. (2006). Anxiety in a neglected

population: Prevalence of anxiety disorders in pre-adolescent children. Clinical

Psychology Review, 26, 816-833. doi:10.1016/j.cpr.2005.12.002

Copeland, W. E., Shanahan, L., Costello, J., & Angold, A. (2009). Childhood and adolescent

psychiatric disorders as predictors of young adult disorders. Archives of General

Psychiatry, 66, 764-772. doi:10.1001/archgenpsychiatry.2009.85

Costello, E. J., Egger, H. L., & Angold, A. (2005). The developmental epidemiology of

19

anxiety disorders: Phenomenology, prevalence, and comorbidity. Child and

Adolescent Psychiatric Clinics of North America, 14, 631-648.

doi:10.1016/j.chc.2005.06.003

Costello, E. J., & Janiszewski, S. (1990). Who gets treated? Factors associated with referral

in children with psychiatric disorders. Acta Psychiatrica Scandinavica, 81, 523-529.

doi:10.1111/j.1600-0447.1990.tb05492.x

Costello, E. J., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A. (2003). Prevalence and

development of psychiatric disorders in childhood and adolescence. Archives of

General Psychiatry, 60, 837-844. doi:10.1001/archpsyc.60.8.837

Ezpeleta, L., Keeler, G., Erkanli, A., Costello, E. J., & Angold, A. (2001). Epidemiology of

psychiatric disability in childhood and adolescence. Journal of Child Psychology and

Psychiatry, 42, 901–914. doi:10.1111/1469-7610.00786

Flament, M. F., Koby, E., Rapoport, J., Berg, C. J., Zahn, T., Cox, D., …Lenane, M. (1990).

Childhood obsessive-compulsive disorder: A prospective follow-up study. Journal of

Child Psychology and Psychiatry, 31, 363-380. doi:10.1111/j.1469-

7610.1990.tb01575.x

Field, A. (2009). Discovering statistics using SPSS (3rd ed.). London, England: Sage.

Ford, T., Goodman, R., & Meltzer, H. (2003). The British Child and Adolescent Mental

Health Survey 1999: The prevalence of DSM-IV disorders. Journal of the American

Academy of Child and Adolescent Psychiatry, 42, 1203-1211. doi:10.1097/00004583-

200310000-00011

Ford, T., Sayal, K., Meltzer, H., & Goodman, R. (2005). Parental concerns about their child’s

emotions and behaviour and referral to specialist services: General population survey.

British Medical Journal, 331, 1435–1436. doi:10.1136/bmj.331.7530.1435

Gowers, S., Thomas, S., & Deeley, S. (2004). Can primary schools contribute effectively to

20

Tier I child mental health services? Clinical Child Psychology and Psychiatry, 9, 419-

425. doi:10.1177/1359104504043924

Green, M. T., Clopton, J. R., & Pope, A. W. (1996). Understanding gender differences in

referral of children to mental health services. Journal of Emotional and Behavioral

Disorders, 4, 182-190. doi:10.1177/106342669600400305

Harris, J. D., Gray, B. A., Rees-McGee, S., Carroll, J. L., & Zaremba, E. T. (1987). Referrals

to school psychologists: A national survey. Journal of School Psychology, 25, 343-

354. doi: DOI: 10.1016/0022-4405(87)90036-7.

Headley, C., J., & Campbell, M.A. (2011). Primary school teachers’ knowledge of what

anxiety is and their ability to identify the signs and symptoms of excessive anxiety.

Paper in preparation

Hibbert, J. A., Fogelman, K., & Manor, O. (1990). Occupational outcomes of truancy. British

Journal of Educational Psychology, 60, 171-179. Retrieved from document delivery

at http://www.qut.edu.au

Ialongo, N., Edlesohn, G., Werthamer-Larsson, L., Crockett, L., & Kellam, S. (1995). The

significance of self-reported anxious symptoms in first grade children: Prediction to

anxious symptoms and adaptive functioning in fifth grade. Journal of Child

Psychology and Psychiatry, 3, 427-437. doi:10.1111/j.1469-7610.1995.tb01300.x

Keppel, G. & Wickens, T. D. (2004). Design and analysis: A researcher’s handbook. Upper

Saddle River, NJ: Pearson Prentice Hall.

Klein, R. G. (2009). Anxiety disorders. Journal of Child Psychology and Psychiatry, and

Allied Disciplines, 50, 153-162. doi:10.1111/j.1469-7610.2008.02061.x

Kovacs, M., & Devlin, B. (1998). Internalizing disorders in childhood. Journal of Child

Psychology and Psychiatry, 39, 47-63. doi:10.1017/S0021963097001765

21

Last, C. G., Hersen, M., Kazdin, A. E., Francis, G., & Grubb, H. J. (1987). Psychiatric illness

in the mothers of anxious children. American Journal of Psychiatry, 144, 1580–1583.

Retrieved from http://ajp.psychiatryonline.org.ezp01.library.qut.edu.au/

Last, C. G., Hersen, M., Kazdin, A. E., Orvaschel, H., & Perrin, S. (1991). Anxiety disorders

in children and their families. Archives of General Psychiatry, 48, 928–934. Retrieved

from document delivery at http://www.qut.edu.au

Last, C. G., & Strauss, C. C. (1990). School refusal in anxiety-disordered children and

adolescents. Journal of the American Academy of Child and Adolescent Psychiatry,

29, 31-35. doi:10.1097/00004583-199001000-00006

Lieb, R., Wittchen, H-U., Hofler, M., Fuetsch, M., Stein, M. B., & Merikangas, K. R. (2000).

Parental psychopathology, parenting styles, and the risk of social phobia in offspring:

A prospective-longitudinal community study. Archives of General Psychiatry, 57,

859–866. doi:10.1001/archpsyc.57.9.859

Lewinsohn, P. M., Gotlib, I. H., Lewinsohn, M., Seeley, J. R., & Allen, N. B. (1998). Gender

differences in anxiety disorders and anxiety symptoms in adolescents. Journal of

Abnormal Psychology, 107, 109-117. doi:10.1037//0021-843X.107.1.109

Loades, M. E., & Mastroyannopoulou, K. (2010). Teachers’ recognition of children’s mental

health problems. Child and Adolescent Mental Health, 15, 150-156.

doi:10.1111/j.1475-3588.2009.00551.x

Lucas, V. L., Collins, S., & Langdon, P. E. (2009). The causal attributions of teaching staff

towards children with intellectual disabilities: A comparison of ‘vignettes’ depicting

challenging behaviour with ‘real’ incidents of challenging behaviour. Journal of

Applied Research in Intellectual Disabilities, 22, 1-9. doi:10.1111/j.1468-

3148.2008.00428.x

Lyneham, H. J., & Rapee, R. M. (2007). Childhood anxiety in rural and urban areas:

22

Presentation, impact and help seeking. Australian Journal of Psychology, 59, 108 –

118. doi:10.1080/00049530701317082

McGorry, P. D., Purcell, R., Hickie, I. B., & Jorm, A. F. (2007). Investing in youth mental

health is a best buy. Medical Journal of Australia, 187(7), S5-7. Retrieved from

https://www.mja.com.au/

McKay, M. M., Stoewe, J., McCadam, K., & Gonzales, J. (1998). Increasing access to child

mental health services for urban children and their caregivers. Health & Social Work,

23, 9-15. Retrieved from http://web.ebscohost.com.ezp01.library.qut.edu.au/

594eb58b04e7%40sessionmgr14&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d

McLean, C. P., & Hope, D. A. (2010). Subjective anxiety and behavioral avoidance: Gender,

gender role, and perceived confirmability of self-report. Journal of Anxiety Disorders,

24, 494-502. doi: 10.1016/j.janxdis.2010.03.006

Messer, S. C., & Beidel, D. C. (1994). Psychosocial correlates of childhood anxiety

disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 33,

975-983. doi:10.1097/00004583-199409000-00007

Molins, N. C., & Clopton, J. R. (2002). Teachers’ reports of the problem behavior of children

in their classrooms. Psychological Reports, 90, 157-164. doi:10.2466/PR0.90.1.157-

164

Norcini, J. (2004). Back to the future: Clinical vignettes and the measurement of physician

performance. Annals of Internal Medicine, 141, 813–814. Retrieved from

http://web.ebscohost.com.ezp01.library.qut.edu.au/

Ollendick, T., King, N., & Yule, W. (1994). International handbook of phobic and anxiety

disorders in children and adolescents. New York: Plenum.

Pearcy, M. T., Clopton, J. R., & Pope, A. W. (1993). Influences on teacher referral of

children to mental health services: Gender, severity, and internalizing versus

23

externalizing problems. Journal of Emotional and Behavioral Disorders, 1, 165-169.

doi:10.1177/106342669300100304

Pine, D. S., Cohen, P., Gurley, D., Brook, J., & Ma, Y. (1998). The risk for early-adulthood

anxiety and depressive disorders in adolescents with anxiety and depressive disorders.

Archives of General Psychiatry, 55, 56–64. doi:10.1001/archpsyc.55.1.56

Rickwood, D. (2005). Supporting young people at school with high mental health needs.

Australian Journal of Guidance and Counselling, 15, 137-155.

doi:10.1375/ajgc.15.2.137

Rickwood, D., Deane, F. P., Wilson, C. J., & Ciarrochi, J. (2005). Young people’s help-

seeking for mental health problems. Australian e-Journal for the Advancement of

Mental Health, 4(3) (Supplement), 1-34. doi:10.1375/ajgc.15.2.137

Rothi, D. M., Leavey, G., & Best, R. (2008). On the front-line: Teachers as active observers

of pupils’ mental health. Teaching and Teacher Education, 24, 1217–1231.

doi:10.1016/j.tate.2007.09.011

Rothi, D., Leavey, G., Chamba, R., & Best, R. (2005). Identification and management of

pupils with mental health difficulties: A study of UK teachers’ experiences and views.

London/Birmingham, England: Barnet, Enfield & Haringey Mental Health

Trust/NASUWT. Retrieved from http://www.playfieldinstitute.co.uk

Rubin, K. H. (1985). Socially withdrawn children: An “at-risk” population? In B. H.

Schneider, K. H. Rubin, & J. E. Ledingham (Eds.), Children’s peer relations: Issues

in assessment and intervention (pp. 125-139). New York: Springer-Verlag.

Saavedra, L. M., Silverman, W. K., Morgan-Lopez, A. A., & Kurtines, W. M. (2010).

Cognitive behavioral treatment for childhood anxiety disorders: Long-term effects on

anxiety and secondary disorders in young adulthood. Journal of Child Psychology

and Psychiatry, 51, 924-934. doi: 10.1111/j.1469-7610.2010.02242.x

24

Sanders, M. R., Tully, L. A., Baade, P. D., Lynch, M. E., Heywood, A. H., Pollard, G. E., &

Youlden, D. E. (1999). A survey of parenting practices in Queensland: Implications

for mental health promotion. Health Promotion Journal of Australia, 9, 105-114.

Retreived from http://search.informit.com.au.ezp01.library.qut.edu.au

Sayal, K. (2006). Annotation: Pathways to care for children with mental health problems.

Journal of Child Psychology and Psychiatry, 47, 649–659. doi:10.1111/j.1469-

7610.2005.01543.x

Spence, S. H. (1998). A measure of anxiety symptoms among children. Behavior Research

and Therapy, 36, 545–566. doi:10.1016/S0005-7967(98)00034-5

Strauss, C. C., Frame, C. L., & Forehand, R. (1987). Psychosocial impairment associated

with anxiety in children. Journal of Clinical Child Psychology, 16, 235-239.

doi:10.1207/s15374424jccp1603_8

Stevenson-Hinde, J., & Shouldice, A. (1993). Wariness to strangers: A behavior systems

perspective revisited. In K. H. Rubin & J. B. Asendorpf (Eds), Social withdrawal,

inhibition, and shyness in childhood (pp.101-116). New York: Lawrence Erlbaum.

Tabachnick, B. G., & Fidell, L. S. (2007). Using Multivariate Statistics (5th ed.). Boston,

MA: Pearson and Allyn & Bacon.

Teagle, S. E. (2002). Parental problem recognition and child mental health service use.

Mental Health Services Research, 4, 257 – 266. doi:10.1023/A:1020981019342

Thurston, I. B., & Phares, V. (2008). Mental health service utilization among African

American and Caucasian mothers and fathers. Journal of Consulting and Clinical

Psychology, 76, 1058-1067. doi:10.1037/a0014007

Zahner, G. E. P., & Daskalakis, C. (1997). Factors associated with mental health, general

health, and school-based service use for child psychopathology. American Journal of

Public Health, 87, 1440-1448. doi:10.2105/AJPH.87.9.1440

25

Zubrick, S. R., Silburn, S. R., Garton, A., Burton, P., Dalby, R., Carlton, J., … Lawrence, D.

(1995). Western Australian Child Health Survey: Developing health and well-being in

the nineties. Perth, WA: Australian Bureau of Statistics and the Institute for Child

Health Research.

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Appendix: Five vignettes used in this study based on vignettes from Green et al. (1996) and

Pearcy et al. (1993).

Very severe anxiety disorder:

Benjamin [Beth] is a shy 10-year-old who worries about tests and grades. He [She] bites his

[her] nails and approaches the teacher's desk with several questions and complaints of

‘tummy pains’ just before a test is to begin. He [She] often cries if he [she] receives a poor

grade or if he [she] is criticized. He [She] very much wants to please his [her] teacher and

parents, and thus fears making mistakes and feels guilty when he [she] does poorly. He [She]

often worries so much about his [her] teachers’ and parents’ expectations that he [she] feels

he [she] cannot breathe and will ask to stay home from school.

Severe anxiety disorder:

Mark [Michelle] is a 10-year-old boy [girl]. He [She] works slowly in the classroom and as a

result often has to take his [her] work home to complete. He [She] seems to procrastinate

often. This is partly due to his [her] excessive fear of making mistakes and oversensitivity to

criticism, as he [she] feels a need to do "perfect" work. He [She] generally finishes his [her]

work and gets good grades, but it takes him [her] much longer than his [her] peers. In

general, he [she] is a child who tends to withdraw and keep things to himself [herself].

Moderate anxiety symptoms:

Joshua [Jess] is a shy 10-year-old boy (girl) who prefers to play alone during recess.

Sometimes, he [she] seems nervous when his [her] peers attempt to engage him [her] in

group activities. When group activities are conducted in the classroom, he [she] participates,

however he [she] is noticeably uncomfortable. When he [she] plays alone, he [she] is creative

and active.

Mild anxiety symptoms:

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Sam [Sarah] is a 10-year-old boy [girl]. He [She] tends to seek excessive attention from his

[her] teacher. When he [she] does not receive attention, he [she] appears sad and withdraws.

He [She] is also overly anxious to please, so he [she] is well behaved in the classroom and

gets good grades. He [she] is proud of his [her] academic achievement and reports his [her]

favorite subjects are Mathematics and Science.

Minimal anxiety symptoms:

Tom [Tegan] is a 10-year-old boy [girl]. He [She] tends to be very talkative in class and has

several good friends. He [She] requires assistance in reading, however does well in

Mathematics and Physical Education. He [she] enjoys taking tests although feels slightly

nervous prior to the test. In addition, he [she] enjoys giving presentations in front of the class

and is a member of the debating team and the class representative.